Early-Neonatal, Late-Neonatal, Postneonatal, and Child Mortality Rates Across India, 1993-2021

Key Points Question How have the early-neonatal, late-neonatal, postneonatal, and child mortality rates in the 36 states and union territories of India changed over the past 30 years? Findings In this repeated cross-sectional study of 232 772 children who died before their fifth birthday in the past 5 years of each survey from each of the rounds of the National Family Health Survey, the lowest mortality rates were observed for the late-neonatal and child periods; the early-neonatal period was the highest, followed by the postneonatal period. Assessing change in absolute terms, child mortality decreased the most; the burden of mortality at early ages is increasingly concentrated in the early-neonatal and postneonatal phase. Meaning The findings of this study suggest that interventions and resources need to be prioritized according to the disaggregated mortality risk in a given area.

NCT Delhi (UT) 9.4 [8.2-10.9]3.6 [2.6-4.9]7.4 [5.9-9.2]6.1 [2.6-14.3]4.2 [2.2-8.3]Puducherry (UT) ---0.9 [0.2-4.7]0 [0-0] Ladakh (UT) -- 15.3 [15.3-15.3]9.9 [9.9-9.9]8.9 [8.9-9] Lakshadweep (UT) ---4.3 [4.2-4.3]0 [0-0] NCT Delhi (UT) 30.9 [30.9-30.9]17. 6 [17.6-17.6] 11.3 [11.3-11.3] 13.7 [13.7-13.7] 7.4 [7.4-7.4 33.5 [31.7-35.2]29. 2 [27.6-30.8] 18.4 [16.9-19.8]9.4 [8.9-9.9]6.9 [6.4-7.4]We searched PubMed and Web of Sciences to identify empirical studies that conducted quantitative analysis on changes in early life mortality across states/Union Territories (UTs) of India using data for at least two time periods.We used structured combinations of keywords: ("Neonatal Mortality" OR "Postneonatal Mortality" OR "Child Mortality" OR "Infant Mortality" OR "Under-five Mortality" OR "Early Neonatal Mortality" OR "Late Neonatal Mortality") AND "India" AND "States" AND ("Trends" OR "Change"), without any time limitations.The search yielded 2560 studies, we found that 22 studies fit the criteria.Out of the 20 studies meeting our criteria, none provided estimates for Postneonatal mortality, but instead grouped it into broader categories of infant or under-five mortality.Only 7 reported neonatal mortality, and four, child mortality (ages 1-4 years), as defined in our study, and three reported early neonatal mortality.While subnational estimates for PNMR in India are available (Kim et al 2020), notably, we are the first to provide subnational trends for the same.While national estimates for early neonatal mortality were available across two or more time periods, none provided a subnational analysis for the same, except one where only regional estimate were provided in place of state wise estimates.The timelines for all 20 studies ranged from 10-32 years, but mainly used data only up to 2016.A single study by Kumar et al (2022) assessed state-level changes up to 2021, but it only examined under-five mortality.In contrast, we study mortality from a 30-year timeline with data as current as 2021.Further, except for Kumar et al (2022) and Bora and Saikia (2015), none offered estimates across all 36 states and union territories.Importantly, none of these studies considered the changing geography of states and UTs in recent decades.They either looked at unaltered regions or treated bifurcated states as one, rendering comparisons meaningless.In contrast, we utilized DHS geographic data to accurately align values with current state boundaries, thus providing estimates for all 36 states and UTs in past periods based on present state divisions.These distinctive attributes of our study set it apart as the most comprehensive subnational assessment of disaggregated mortality in India.It was launched to prevent nutritional anaemia in mothers and children-given one tablet of iron and folic acid containing 60 mg elementary iron which was raised to 100 mg elementary iron, however folic acid content remained the same (0.5 mg of folic acid) and children in the age group of 1-5 years are given one tablet of iron-containing 20 mg elementary iron (60 mg of ferrous sulphate and 0.1 mg of folic acid) daily for a period of 100 days.National Vitamin A Prophylaxis program It was launched to prevent nutritional blindness.Under this strategy, every infant 6-11 months and children 1-5 years is to be administered vitamin A every 6 months.The recommended schedule is as follows: 6-11 months 1-5 years • one doze of 100,000 IU -200,000 IU/6 months A child must receive a total of 9 oral doses of vitamin A by its firth birthday Special Nutrition Program It provides supplementary feeding of about 300 calories and 10 grams of protein to preschool children and about 500 calories and 25 grams of protein to expect at and nursing mothers for six days a week.It is a center established in the health facility for the purpose of providing lactation support to all mothers within the health facility for collection, storage, and dispensing of a mother's own breast milk for consumption by her baby.

Mothers Absolute Affection
Aims to revitalize efforts towards the promotion, protection and support of breastfeeding practices through health systems to achieve higher breastfeeding rates Pradhan Mantri Surakshit Matritva Abhiyaan The program aims to provide assured, comprehensive and quality antenatal care, free of cost, universally to all pregnant women on the 9th of every month Labour room Quality improvement Initiative The program will benefit every pregnant woman and newborn delivering in public health institutions.Program will improve quality of care for pregnant women in labour room, maternity Operation Theatre and Obstetrics Intensive Care Units (ICUs) & High Dependency Units (HDUs).Anemia Mukt Bharat It has been designed to reduce the prevalence of anemia by 3 percentage points per year among children, adolescents and women in the reproductive age group (15-49 years), between the year 2018 and 2022 POSHAN Abhiyaan The programme, through use of technology, convergence and community involvement with a targeted approach strives to reduce the level of stunning, under-nutrition, Anemia and low birth weight in children, as also focus on adolescent girls, pregnant women and lactating mothers, thus holistically addressing malnutrition.Surakshit Matritva Aashwasan (SUMAN) It aims to provide assured, dignified and respectful delivery of quality healthcare services at no cost and zero tolerance for denial of services to any woman and newborn visiting a public health facility in order to end all preventable maternal and newborn deaths and morbidities and provide a positive birthing experience Thalassemia Bal Sewa Yojna It aims to provide a one-time cure opportunity for Haemoglobinopathies like Thalassaemia and Sickle Cell Disease for patients who have a matched family donor; and montly family icome is below INR 20000 Intensified Diarrhoea Control Fortnight It consists of a set of activities to be implemented in an intensified manner for prevention and control of deaths due to dehydration from diarrhoea across all States & UTs.These activities mainly include-the intensification of advocacy & awareness generation activities for diarrhea management, strengthening service provision for diarrhea case management, the establishment of ORS-Zinc corners, prepositioning of ORS by ASHA in households with under-five children, and awareness generation activities for hygiene and sanitation Intensified Mission Indradhanush The scheme seeks to drive towards 90% full immunization coverage of India and sustain the same by the year 2022 the probability of dying in the first month of life; Postneonatal mortality: the difference between infant and neonatal mortality (similar to the probability of dying during months 1 through 11, but different); Infant mortality: the probability of dying in the first year of life; Child mortality: probability of dying between the first and fifth birthday; Under-five mortality: the probability of dying before the fifth birthday.
When these are multiplied by 1000, they are referred to as NMR, PNMR, IMR, CMR, and U5MR, respectively The set of 5 is obtained from the set of 8 as follows: This program produces a 28-day neonatal rate, plus early neonatal and late neonatal rates.Those rates are just produced using a 60-month window of births, e.g.b19=1 to 61, with no censoring of neonatal deaths.The difference between the 28-day q1 and the usual q1 is added into q2, for months 2-3.Because of the slippage in the definition of the window, the post neonatal rate does not necessarily go up.It may go either up or down, but by a small amount.

States/Union Territories Live Births Early-neonatal Late-neonatal Postneonatal Child
All values are significant to p<0.01, and values are rounded to 2 decimal places.Standard Deviation (SD) and Interquartile Range (IQR) of Early-neonatal, Late-neonatal, Postneonatal and Child Mortality Rates of States/Union Territories of India, 1993-2021 Note: Values are expressed in per 1,000 live births and are rounded to 1 decimal place.Distribution of the Observed Sample of Live Births, Early-neonatal, Late-neonatal, Postneonatal, and Child Deaths across all States/Union Territories, 1993 Distribution of the Observed Sample of Live Births, Early-neonatal, Late-neonatal, Postneonatal, and Child Deaths across all States/Union Territories, 1999 Distribution of the Observed Sample of Live Births, Early-neonatal, Late-neonatal, Postneonatal, and Child Deaths across all States/Union Territories, 2006 eTable 7: Percentage Share of the Burden of Early-neonatal, Late-neonatal, Postneonatal and Child Mortality to Under 5 Mortality across States/Union Territories of India, 1993-2021 eTable 8:

States/Union Territories Live Births Early-neonatal Late-neonatal Postneonatal Child
Relationship between Standardized Absolute Change (1993-2021)and baseline Early-neonatal,Late-neonatal, Postneonatal and Child Mortality Rates (1993)across States/Union Territories of India

eFigure 2: Interactive Dashboard showing
Geographic Distribution of Early-neonatal, Late-neonatal, Postneonatal and Child mortality rates across the States and Union Territories of India, 1993-2021 https://geographicinsights.iq.harvard.edu/State-Child-MortalityeMethods 1: Systematic search of prior literature
Details of quantitative subnational (state-level) evidence on early life mortalities in India with data for at least two time periods doi:10.21106/ijma.19Paul, V. K., Sankar, M. J., & Saini, S. Trek to MDG 4: state of Indian States Sample Registration Survey Paul, Vinod K et al. "Trek to MDG 4: state of Indian States."Indian journal of pediatrics vol.81,10 (2014): 993-9.doi:10.1007/s12098-013-1324-0 Home Based New Born Care launched for accelerated reduction of Neonatal mortality and morbidity rates especially in rural, remote areas where access to care is largely unavailable or located faraway National Health Mission Combines National Rural and Urban Health Missions-aims to provide equitable and quality primary healthcare services to the urban population with a special focus on slum and vulnerable sections of the society.Integrated Action Plan for Pneumonia and Diarrhea It aims at ending preventable child deaths from pneumonia and diarrhea by 2025 National Iron Plus Initiative Under National Iron+ Initiative, the following age groups are covered for lifelong supplementation of Iron from the age of 6 months onwards: Bi-weekly 20 mg elemental iron and 100 micrograms (mcg) folic acid per ml of liquid formulation and age-appropriate deworming for preschool children of 6-59 month Rashtriya Bal Swashta Krayakram It aims to improve the overall quality of life of children enabling all children to achieve their full potential, and also provide comprehensive care to all the children in the community.This program involves screening children from birth to 18 years of age for 4 Ds-Defects at birth, Diseases, Deficiencies, and Development delays, spanning 32 common health conditions for early detection and free treatment and management, including surgeries at the tertiary level Safe Motherhood Booklets Started along with National Health Mission to provide essential information to all pregnant women about maternal and child healthcare Weekly Iron Folic Acid Supplementation Programme WIFS is an evidence-based programmatic response to the prevailing anemia situation amongst adolescent girls and boys through supervised weekly ingestion of IFA supplementation and biannual helminthic control.The long-term goal is to break the intergenerational cycle of anemia.India Newborn Action Plan Six pillars of intervention packages impacting stillbirths and newborn health have been identified, which include: Preconception and antenatal care, Care during labour and childbirth, Immediate newborn care, Care of healthy newborns, Care of small and sick newborns, Care beyond newborn survival Lactation Management Centers It is one of the six services provided under the Integrated Child Development Services (ICDS) Scheme which is primarily designed to bridge the gap between the Recommended Dietary Allowance (FDA) and the Average Daily Intake (ADI).Janani Shishu Suraksha KaryakramIt entitles all pregnant women delivering in public health institutions to absolutely free and no expense delivery including Caesarean section © 2024 Subramanian SV et al.JAMA Network Open.
The UNWEIGHTED deaths and risk are used, with adjustments for weights, clusters, and strata within the model.Do not alter the usual glm model.We want to include the IMR, CMR, and U5MR as usually calculated * The early neonatal, late neonatal, and neonatal rates will come from a separate model.* The Postneonatal rate will be adjusted so that it is the difference between IMR and NMR28 * Save as scalars. * table r(table) after nlcom, so we must calculate ci's from B and V * This approach produces symmetric confidence intervals, unfortunately Compressed code for constructing the rates, with c.